REVIEW

Patient participation in patient safety and nursing input – a systematic

review
Mojtaba Vaismoradi, Sue Jordan and Mari Kangasniemi

Aims and objectives. This systematic review aims to synthesise the existing
research on how patients participate in patient safety initiatives. What does this paper contribute
Background. Ambiguities remain about how patients participate in routine mea- to the wider global clinical
sures designed to promote patient safety. community?
Design. Systematic review using integrative methods. • Patients are able and willing to
Methods. Electronic databases were searched using keywords describing patient participate in patient safety ini-
involvement, nursing input and patient safety initiatives to retrieve empirical tiatives.
research published between 2007 and 2013. Findings were synthesized using the
• Efforts to involve patients in sys-
tems to ensure their own safety
theoretical domains of Vincent’s framework for analysing risk and safety in clinical should accommodate patients’
practice: “patient”, “healthcare provider”, “task”, “work environment”, “organi- abilities and health beliefs, their
sation & management”. personal illness coping strategies
Results. We identified 17 empirical research papers: four qualitative, one mixed- and their past experiences in the
method and 12 quantitative designs. All 17 papers indicated that patients can par- healthcare system.
• Nurses’ positive attitudes,
ticipate in safety initiatives.
encouragement and support, and
Conclusions. Improving patient participation in patient safety necessitates consid- pre- and post-registration nurse
ering the patient as a person, the nurse as healthcare provider, the task of partici- education are central to patient
pation and the clinical environment. Patients’ knowledge, health conditions, participation in safety measures.
beliefs and experiences influence their decisions to engage in patient safety initia- Appropriate infrastructures and
working environments also are
tives. An important component of the management of long-term conditions is to
required.
ensure that patients have sufficient knowledge to participate. Healthcare providers
may need further professional development in patient education and patient care
management to promote patient involvement in patient safety, and ensure that
patients understand that they are ‘allowed’ to inform nurses of adverse events or
errors. A healthcare system characterised by patient-centredness and mutual
acknowledgement will support patient participation in safety practices. Further
research is required to improve international knowledge of patient participation
in patient safety in different disciplines, contexts and cultures.
Relevance to clinical practice. Patients have a significant role to play in enhancing
their own safety while receiving hospital care. This review offers a framework for
clinicians to develop comprehensive practical guidelines to support patient
involvement in patient safety.

Authors: Mojtaba Vaismoradi, PhD, MScN, BScN, Researcher, Fac-
ulty of Professional Studies, University of Nordland, Bodø, Norway;
Sue Jordan, Reader, College of Human and Health Sciences, Swan-
sea University, Swansea, UK; Mari Kangasniemi, PhD, RN, Docent,
University lecturer, Department of Nursing Science, Faculty of
Health Sciences, University of Eastern Finland, Kuopio, Finland
Correspondence: Mari Kangasniemi, Docent, University lecturer,
Department of Nursing Science, Faculty of Health Sciences, Univer-
sity of Eastern Finland, P.O. Box 1627, Kuopio 70211, Finland.
Telephone: + 358 40 355 3624.
E-mail: mari.kangasniemi@uef.fi

© 2014 John Wiley & Sons Ltd

Journal of Clinical Nursing, doi: 10.1111/jocn.12664 1
M Vaismoradi et al.
Key words: integrative review, patient participation, patient safety, safety man-
agement
Accepted for publication: 21 June 2014
Introduction
Patient safety is “the prevention of errors and adverse
events associated with provision of healthcare” (World
Health Organization 2013 p. 1). Patient safety and error
reduction are the shared responsibility of all healthcare
professionals, and improvement depends on recruitment,
education and performance of the whole multidisciplinary
team (Leape 2009, International Council of Nurses 2012,
Vaismoradi et al. 2012). There is international interest in
involving patients in healthcare planning and service devel-
opment (Andersson & Olheden 2012).
Patient participation in healthcare planning, service
development and research is a key policy component in
many countries (Johnstone & Kanitsaki 2009, Longtin
et al. 2010, Broer et al. 2014). Patients are dependent
on healthcare professionals, and their decision making
(Bovenkamp & Trappenburg 2009), however, their involve-
ment in safety initiatives is crucial to the management of
long-term conditions (Andersson & Olheden 2012) and
improving safety (Davis et al. 2007, Entwistle 2007,
Armstrong et al. 2013). Some authors suggest that health-
care providers rely on patients to check on the delivery of
their care to ensure their own safety (Entwistle 2007), and
in some adverse events, patients are the first link in the
reporting chain (Lyons 2007). Benefits of patient participa-
tion include raising awareness of adverse events (Pinto
et al. 2013) and patient empowerment (Bovenkamp &
Trappenburg 2009). It is believed that possibility of preven-
tion of incidents is a main motivation for engaging patients
in patient safety initiatives (Schwappach 2010). Many
patients are willing and able to help with preventing prac-
tice errors (Zhang et al. 2012), but ambiguity remains over
how patients can participate in patient safety activities
(Davis et al. 2012a, Armstrong et al. 2013). Therefore, sys-
tematically reviewing the literature to identify the most
appropriate models, clarify and describe the distinctive roles
of the patient will expedite development of effective patient
involvement strategies.
Aims
The purpose of this systematic review focuses on nursing,
to develop an understanding of how patients can participate
2 Journal of Clinical Nursing
in patient safety initiatives and the factors affecting their
participation, using the ‘framework of contributory factors
influencing clinical practice’ (Vincent et al. 1998, p. 1156,
Vincent 2010, p. 150): ‘patient’, ‘healthcare provider’,
‘task’, ‘work environment’, ‘organisation & management’
to present a schematic model.
Methods
Design
A systematic review using an integrative method was con-
ducted. Systematic reviews collect data using clear and
explicit processes (Liberati et al. 2009, Higgins & Green
2011), followed by systematic synthesis of the characteris-
tics and findings of the included studies to answer the
study question (Evans 2001, Mantzoukas & Watkinson
2007).
Integrative reviews reconcile diverse data sources, includ-
ing both quantitative and qualitative studies, to enhance the
holistic understanding of the topic of interest. This ecumen-
ical approach, combining quantitative and qualitative stud-
ies, ensures comprehensive coverage, relevant to clinical
practice (Whittemore & Knafl 2005).
Data gathering
Search strategy
We identified the review question and keywords in consul-
tation with an expert librarian and collected the relevant
empirical research papers published 2007–2013 in journals
included from online databases: PubMed (including Med-
line), CINAHL, SCOPUS, Wiley Online Library and Science
Direct. On the basis of pilot testing in the electronic data-
bases and the authors’ experiences of key terms commonly
used in the international literature, to maximise cover-
age, we applied the following key search terms together:
‘patient safety’ and ‘nurse’ combined with ‘participation’ or
‘involvement’ or ‘engagement’ or ‘role’ in any part of the
articles. The search strategy and results of different phases
of the systematic review are presented in Table 1. Research
articles in languages other than English were excluded due
to translation issues and inaccessibility, but the search strat-
egy did not impose any language limitations.
© 2014 John Wiley & Sons Ltd
Review Patient participation and patient safety

Inclusion criteria
The inclusion criteria for the electronic search were: (1)
focused on patient participation/involvement/engagement/
role in patient safety, (2) published in online scientific jour-
nals and (3) nursing involvement.
Exclusion criteria were: (1) patient participation/involve-
ment/engagement in healthcare of no relevance to patient
safety, (2) related solely to professions other than nursing
and (3) no empirical data.
inclusion criteria 1–3 (n = 17). The full texts were obtained
from UK and Finnish libraries. The full texts of the articles
were read and checked for quality using criteria developed
by Hawker et al. (2002): (1) clearly defined aim of the
study, (2) sound and logical structure of research, (3) expli-
cit theoretical/conceptual framework of research, (4) expli-
cit conclusion, and (5) relevant references. All 17 papers
met the quality criteria and were included into the final
analysis (Fig. 1).

Progression of systematic review and quality of studies Theoretical framework

Each phase of the systematic review was conducted by two
authors independently (MV, MK). Discussions were held
throughout the study and agreed on the search process.
Firstly, a thorough literature search was performed using
the key terms (Table 1) based on the lexicon of PubMed
(including Medline), CINAHL, SCOPUS, Wiley Online
Library and Science Direct (n = 4683). Secondly, retrieved
articles were selected by titles using inclusion criteria 1 and
2, and duplicate titles were deleted (n = 123). In the next
phase, the abstracts of the articles were checked using
Vincent’s ‘framework of contributory factors influencing
clinical practice’ (Vincent et al. 1998, p. 1156, Vincent 2010,
p. 150), developed from Reason’s ‘organisational accident
model’ (Reason 2001), was used to describe the data
retrieved from the studies in relation to patient participation
in patient safety. We deployed a theoretical framework to
accommodate the considerable heterogeneity in studies in
terms of methods, participants and interventions (Popay
et al. 2006), and develop the primary explanation of how
and why a particular strategy can be followed in practice.

Table 1 The search strategy and results of different phases of the systematic review process

Selections based Selections based Selections based on full text

Years Database and search terms Total on title on abstract and inclusion criteria

2007–2013 Cinahl
PS + participation + nurse 2052 24 6 6
PS + involvement + nurse
PS + engagement + nurse
PS + role + nurse
Scopus
PS + participation + nurse 655 7 1 1
PS + involvement + nurse
PS + engagement + nurse
PS + role + nurse
PubMed
PS + participation + nurse 1086 19 1 1
PS + involvement + nurse
PS + engagement + nurse
PS + role + nurse
Wiley Online Library
PS + participation + nurse 491 52 9 9
PS + involvement + nurse
PS + engagement + nurse
PS + role + nurse
Science Direct
PS + participation + nurse 399 21 0 0
PS + involvement + nurse
PS + engagement + nurse
PS + role + nurse
Total 4683 123 17 17

PS, patient safety.

© 2014 John Wiley & Sons Ltd

Journal of Clinical Nursing 3
M Vaismoradi et al.

Retrieved articles based on the Figure 1 Systematic review progression.

search strategy (n = 4683)

Rejected articles based on titles that did not

conform to the inclusion criteria 1 (n = 4560)

Articles based on titles (n = 123)

Rejected articles based on abstracts that did not

conform to the inclusion criteria 2 and 3 (n
= 106)
Articles based on abstracts (n = 17)

Rejected articles based on full-texts appraisal

(n = 0)

Articles based on full-texts (n = 17)

involvement favourably and agree that they should take an

Results
Characteristics of selected studies
The studies’ findings did not lend themselves to meta-analy-
sis due to variations in methodologies.
Table 2 summarises the characteristics of the studies
included in this systematic review. All studies were pub-
lished between 2010–2013. Nine studies were conducted in
the UK (Davis et al. 2011a, 2012a,b,c,d, 2013a,b, Lawton
et al. 2011, Rainey et al. 2013). Five were conducted in
Switzerland (Schwappach & Wernli 2010a,b, Schwappach
et al. 2010, 2013a,b). One was conducted in the USA
(Rathert et al. 2011), one in Sweden (Flink et al. 2012) and
one in China (Zhang et al. 2012).
Four studies used qualitative methods (Schwappach &
Wernli 2010a, Schwappach et al. 2010, Flink et al. 2012,
Rainey et al. 2013), two mixed-method designs (Davis et al.
2013a,b) and the remaining 11 were quantitative studies.
Of the quantitative studies, nine articles were cross-sectional
surveys and two used interventional designs.
Patient participation in patient safety
The question of how patients can participate in patient
safety was answered through classification of the findings
around an established theoretical framework (Vincent
2010) in a schematic model (Fig. 2).
Patient
In general, patients approve of their role in detecting and
preventing errors (Schwappach et al. 2010), view patient
active role (Davis et al. 2012b). Through asking questions
and reporting their observations of deviations from rou-
tines, patients show their willingness to engage with and be
proactive in safety practices (Schwappach & Wernli
2010a).
However, some patients reject active participation,
because they feel that this is not their role (Schwappach
& Wernli 2010a) or are disinclined to be proactive
towards patient safety and prefer to cede control to
healthcare professionals (Rathert et al. 2011) or feel
themselves confined to a passive role and are content
with merely receiving information about care and treat-
ment (Flink et al. 2012). For examples, some participants
in Flink et al.’s (2012) study believed that healthcare pro-
viders had all the necessary information in the medical
records, either from previous admissions or from shared
medical records, stating: ‘what they need to know is
already in my medical record, everything is in there. (p.
i179)’.
Patients knowledgeable about patient safety and familiar
with their own care are more likely to engage in patient
safety initiatives (Schwappach & Wernli 2010b, Zhang
et al. 2012) and able to monitor and detect any practice
errors related to their own care (Davis et al. 2013b, Rainey
et al. 2013). However, not all patients feel adequately
informed: ‘I did not receive adequate information from
healthcare providers to know what to expect in terms of
my treatment. Staff assumed I knew what was happening
and did not provide me with any useful information’ (Davis
et al. 2013b, p. 4). Failure to inform patients as to the
likely outcomes of treatment could increase the risks that

© 2014 John Wiley & Sons Ltd

4 Journal of Clinical Nursing
Review
Table 2 Characteristics of the studies
Author(s), year,
country Aim
Schwappach & To assess chemotherapy patients’ perceptions
Wernli (2010a), of safety and their attitudes towards
Switzerland participating in error prevention strategies
Schwappach To explore oncology nurses’ perceptions and
et al. (2010), experiences with patient involvement in
Switzerland chemotherapy error prevention
Schwappach & To analyse attitudes, norms, behavioural
Wernli control, and chemotherapy patients’
(2010b), intentions to participate in medical error
Switzerland prevention
Rathert et al. To explore the results of a qualitative study
(2011), U.S. in which patients reported their ideas about
what they believe their roles should be
Davis et al. To investigate medical and surgical patients’
(2011a), UK perceived willingness to participate in
different safety-related behaviours and the
potential impact of doctors’/nurses’
encouragement on patients’ willingness
Lawton et al. To investigate the extent to which outcome of
(2011), UK care (harm or not) and relationship (good or
bad) with the care provider impact on
judgements of responsibility and blame as
well as decisions about likelihood of making
a complaint
Davis et al. To examine predictors of patients’ intentions
(2012a), UK to engage in two safety behaviours: (1)
reminding healthcare staff to wash their
hands and; (2) notifying healthcare staff if
they are not wearing a hospital identification
bracelet
Davis et al. To investigate patients’ willingness to be
(2012b), UK involved and healthcare professionals’
willingness to support patient involvement in
pretransfusion checking behaviours
Davis et al. To examine patients’ and healthcare
(2012c), UK professionals’ attitudes towards a video
aimed at promoting patient involvement
in safety-related behaviours
Davis et al. To investigate physicians’ and nurses’
(2012d), UK attitudes towards patient involvement in
safety-related behaviours
© 2014 John Wiley & Sons Ltd
Journal of Clinical Nursing
Patient participation and patient safety
Methods Results
Qualitative design Participants unequivocally agreed that patients
using content can make contributions to their safety, and
analysis many patients were prepared to get involved.
Patients described engaging in their safety as
a learning process and highlighted the
importance of being proactive
Qualitative descriptive Participants shared affirmative attitudes and
study using inductive overwhelmingly reported positive experiences
theme-identification with engaging patients in safety behaviours,
content analysis although engaging patients was described as
a challenge
Cross-sectional Patients acknowledged the benefit of error
survey monitoring and reporting and anticipated
positive outcomes of involvement, but their
evaluations of the process of engaging in error
prevention were less positive
Survey using a Patients believed they should be able to trust
mailing method that they are being provided competent care,
as opposed to assuming a leadership role in
their safety
Cross-sectional Patients do not view involvement in a range
exploratory study of safety-related behaviours uniformly
using a survey
Questionnaire Participants made significantly more negative
vignettes ratings in response to vignettes describing a
bad outcome and a poor relationship with
the health professional
Cross-sectional Control beliefs, normative beliefs and
survey perceived severity were the strongest
predictors of patients’ intentions to
participate in both behaviours
Cross-sectional Patients and healthcare professionals view
design using patient involvement in transfusion-related
survey behaviours quite favourably and appear in
agreement regarding patients’ active roles
Experiment, using Video may be effective at changing patients’
a within-subjects and healthcare professionals’ attitudes
design towards patient involvement in some,
but not all, safety-related behaviours
Cross-sectional Both professions held positive attitudes
exploratory study towards patient involvement, although in
using two surveys general, nurses vs. physicians were more
willing to both support patient involvement
and participate themselves as a patient
5
M Vaismoradi et al.

Table 2 (Continued)

Author(s), year,
country Aim Methods Results

Flink et al. To improve the knowledge and understanding Qualitative design Patients participated by exchanging
(2012), Sweden of patients’ perspectives about their with content information, and making contact with and
participation in handover analysis conveying information to their next
healthcare provider
Zhang et al. To investigate the baseline status of patients’ Cross-sectional Patients expressed willingness to contribute
(2012), China awareness, knowledge, and attitudes to survey to patient safety, but their knowledge about
patient safety in China, and to determine the patient safety practices was generally very
factors that influence patients’ involvement limited
in patient safety
Davis et al. To evaluate patients’ attitudes towards a Two exploratory Video and leaflet could be effective at
(2013a), UK video and leaflet aimed at encouraging studies employing encouraging patient involvement in some
patient involvement in safety-related a within-subjects safety-related behaviours
behaviours mixed-methods
design
Davis et al. To investigate hospital patients’ reports of Cross-sectional Patients were more willing to report
(2013b), UK undesirable events in their healthcare mixed-methods undesirable events to a researcher than to a
design local or national reporting system
Rainey et al. To examine the experiences and views of Qualitative design Safety strategies based on patient involvement
(2013), UK patients and their relatives to determine the using thematic must take account of the complexities of
potential for involvement in promoting their analysis acute illness
own safety
Schwappach To investigate how healthcare professionals Cross-sectional Approval of patients’ safety-related
et al. (2013a), (HCPs) evaluate patients’ behaviours survey interventions was generally high and
Switzerland affected by patients’ behaviour and
identification of error
Schwappach To investigate the effects of patient safety Quasi-experimental Patients in the intervention group were less
et al. (2013b), advice on patients’ risk perceptions, intervention study likely to feel poorly informed about
Switzerland perceived behavioural control, performance medical errors
of safety behaviours and experience of
adverse incidents

Vincent’s framework
Patient HPC Task WE O&M

Role Knowledge, Nature of task Open Responsibility

Patient safety

approval Belief & attitude atmosphere

Participation
Participation factors

Patterns &
Knowledge Value of strategy
Support & routines
belief & participation
attitude encouragement Infrastructure
Orientation & Role models & resources
Past Education & ability
experiences Time for
training
patient and
Physical staff education
Teamwork
condition

Patient participation in safety as a process

Figure 2 Schematic model of patient participation in patient safety based on the Vincent’s framework. HPC, Healthcare provider; WE,
Work environment; O & M, Organisation & management.

© 2014 John Wiley & Sons Ltd

6 Journal of Clinical Nursing
Review
treatment complications would not be detected in time to
avoid readmission to hospital.
The benefits of patient participation in safety initiatives
depend on patients being aware of the need for their
involvement (Flink et al. 2012). Patients willingly partici-
pate, if they perceive this as a normal and acceptable
behaviour, within their control. Therefore, to design inter-
ventions to encourage patient participation in safety pro-
jects, understanding of patients’ health beliefs and attitudes
is needed. Patients actively given permission to participate
have a sense of control. Perceptions of control, perceived
severity of errors and empowerment are key ingredients of
any patient involvement in safety interventions (Davis et al.
2012a). If patients find that healthcare providers avoid
partnership or leave their concerns unresolved, they lose
confidence in professionals and avoid future contact and
cooperation (Flink et al. 2012, Rainey et al. 2013).
Patients’ health status is a key requirement for their par-
ticipation in patient safety. The ability of patients to partic-
ipate in safety projects is reduced by illness, but patients’
relatives may be able to fulfil this role (Rainey et al. 2013).
However, this strategy has to be used cautiously, as the
involvement of relatives can sometimes impede patient
involvement (Schwappach et al. 2010, 2013b, Flink et al.
2012, Rainey et al. 2013).
Healthcare provider
Professionals need to be reassured that patients’ prompts
are neither challenge to their competence nor attempts to
undermine care. Professionals have a pivotal role in facili-
tating patient participation in patient safety. Encourage-
ment and approval by healthcare staff are crucial in
preparing patients for engagement in promoting the safety
of their own care (Schwappach & Wernli 2010a,b). Nurses’
positive attitudes, encouragement, support and education
were identified as central to patient participation in safety
practices (Davis et al. 2011a, 2012c).
Responding to the information provided by patients, indi-
cating understanding of their conditions, and meeting their
needs are examples of positive attitudes and behaviours
(Flink et al. 2012). Professionals accepting patient involve-
ment and questioning reduce social barriers, and improve
patients’ feeling of trust in their own ability to engage in
safety practices (Schwappach & Wernli 2010b).
Patient involvement in patient safety should be perceived
as helping to develop trusting relationships between
patients and healthcare providers, and many nurses support
this (Davis et al. 2012d). Stimulating patients to engage in
© 2014 John Wiley & Sons Ltd
Journal of Clinical Nursing
Patient participation and patient safety
safety initiatives is a challenge (Schwappach et al. 2010,
Davis et al. 2012d). For example, some patients are afraid
of causing offence to healthcare professionals by raising
concerns or complaining about errors, because it ‘. . .looks
like you are dictating to them (staff) how to do their job
(Davis et al. 2013a, p. 7)’.
Nurses’ encouragement influences patients’ willingness to
ask questions about safety issues (Davis et al. 2011a,
2012c). Single episodes of patients’ negative reactions or
challenging behaviours may be overrated by healthcare pro-
fessionals and have the potential to erode bilateral relation-
ships and any positive attitudes towards patient
involvement (Schwappach et al. 2013a). Oncology nurses
switch between participative and authoritative models,
using different communication styles to engage patients by
mandating them to read medicines’ labels and report any
concerns (Schwappach et al. 2010). For example, a nurse
declared:
I ask them for their help . . . that they support me in my work. It
would help me a lot if you could also watch out that everything is
correct. I mandate them to read the labels with me. I mandate
them to report anything they feel is not okay. I use this term “man-
date,” and I feel that is something they can understand and accept.
(p. E87)
Healthcare professionals may have limited expertise in
recruiting patients to participate in safety initiatives
(Schwappach et al. 2010). Professional education should
include the importance of avoiding negative reactions to
perceived ‘challenges’ and discouraging responses
(Schwappach et al. 2013a), and effective communication on
error prevention and questioning safety practices (Davis
et al. 2012b). Professionals should perceive patient educa-
tion in safety as a core, but challenging, element of their
role that advances their expertise (Schwappach et al. 2010).
Professionals engaging patients in their safety need to be
aware that not all patients want or are able to participate,
and that this will change over time and with context. With
these caveats, patient involvement in safety is a promising
strategy and an opportunity to strengthen trust and team
building (Schwappach & Wernli 2010a).
Although not all retrieved studies discussed the role of
healthcare teams in patient participation in safety,
Schwappach et al. (2010) report that participant nurses per-
ceived patients’ involvement challenging and support from
other team members and professional development was
helpful. For example, nurses identified a high level of fluc-
tuation in team organisation and staff assignments as the
main barrier to patient safety.
7
M Vaismoradi et al.
Task
The nature of tasks given to patients for participation in
patient safety is important. Patients need to understand that
adverse events are unintended, but may cause actual or
potential harm (Schwappach & Wernli 2010a) and that
patients’ reports of practice errors are not considered to be
complaints. Patients will engage in safety activities, if
enough information about the nature of the task is pro-
vided. However, if patients experience preventable errors or
fail to report them during hospitalisation, the potential for
frustration is high (Schwappach et al. 2010).
Most patients need orientation and education due to lack
of knowledge about healthcare routines and procedures and
how to detect and report changes in their clinical condi-
tions (Rainey et al. 2013). While essential to care, fast and
unexpected changes in procedures and medicine administra-
tion techniques are perplexing to patients and may decrease
patients’ participation (Schwappach et al. 2010, Rainey
et al. 2013).
Participation in safety proceeds gradually, from novice to
‘expert patient’ (Schwappach & Wernli 2010a). Knowledge,
abilities and resources vary among patients. Therefore, vari-
ous tasks and roles at the different stages of the treatment
process should be defined to ensure attraction of patient
participation (Schwappach et al. 2010, 2013a).
Work environment
The social milieu of the workplace should be considered
with regard to its conducivity to patient safety communica-
tion. Patients’ contributions provide important feedbacks to
consolidate safety practice in the healthcare team
(Schwappach et al. 2010). This should be a normal compo-
nent of healthcare, a valuable resource for the exchange of
information within healthcare teams (Flink et al. 2012),
and a link between patients and healthcare providers
(Schwappach & Wernli 2010a). Patients understand the
implication of error monitoring and reporting and expect
positive outcomes from their safety involvement (Schwapp-
ach & Wernli 2010b).
Asking questions, communicating with staff, reporting
observations of deviations from standard and familiar proce-
dures and work routines are some of the ways that patients
reduce healthcare harms (Schwappach & Wernli 2010a,
Davis et al. 2013a). Patients can challenge deviations from
routines. Empowering patients to learn about their own
health condition can be coupled with motivating them to
ask questions (Rathert et al. 2011). However, providing
patients with safety-related information may generate
8 Journal of Clinical Nursing
negative emotions and beliefs that undermine trust in health-
care professionals (Schwappach et al. 2010, Davis et al.
2013a).
Holding open discussions with healthcare professionals
normalises patients’ involvement in safety-related behav-
iours and thus improves their acceptability (Davis et al.
2013a). Partnership and bilateral relationships between
patients and healthcare professionals are required to create
an environment that values patient participation. Patients’
efforts to participate and prevent errors should be wel-
comed with a focus on avoiding negative reactions from
healthcare professionals (Davis et al. 2013a). Poor relation-
ships with professionals influence the likelihood of patients
complaining and apportioning blame and responsibility
(Lawton et al. 2011, Rainey et al. 2013). Positive encoun-
ters, patient empowerment and patients’ trust in their pro-
viders are important factors affecting patients’ willingness
to participate (Flink et al. 2012).
Educating and encouraging patients to directly report
incidents should be planned to enhance patient participa-
tion in their healthcare management (Davis et al. 2013b).
Teaching through video has been shown to increase
patients’ perceived comfort in engaging in safety-related
behaviours (Davis et al. 2012c, 2013a). Providing advice
and positive reactions to patients’ complaints including
talking to the patient in a relaxed manner and at his/her
bedside are useful strategies to communicate about safety
(Flink et al. 2012, Schwappach et al. 2013b). These
approaches engender more realistic risk perceptions
(Schwappach et al. 2013b).
Providing role models of similar patients who already
have participated in harm prevention activities are helpful
(Schwappach & Wernli 2010b), and serves to facilitate
communication about professionals’ errors (Schwappach
et al. 2013b).
Organisation & management
While safety is the nurses’ responsibility and patients’ par-
ticipation is complementary to nurses’ efforts (Schwappach
et al. 2010), providing an appropriate and positive environ-
ment to involve patients in patient safety is the responsibil-
ity of healthcare managers (Rathert et al. 2011). The
healthcare environment offers infrastructures and resources
to facilitate the collaboration between the healthcare pro-
fessionals and patients to encourage patient participation in
safety practices (Schwappach & Wernli 2010b). To encour-
age patient participation, the healthcare system needs to
promote patient-centredness, mutual acknowledgement,
relatedness and continuity (Rathert et al. 2011). Workload,
© 2014 John Wiley & Sons Ltd
Review
general time constraints and organisational processes that
prevent nurses from educating patients hinder appropriate
patients’ participation in patient safety. While safety is the
nurses’ responsibility and patients’ participation is comple-
mentary to nurses’ efforts (Schwappach et al. 2010), pro-
viding an appropriate and positive environment to involve
patients in patient safety is the responsibility of healthcare
managers (Rathert et al. 2011).
It is important to collect data to investigate patient-
related, healthcare professional-related factors and organi-
sational culture affecting interventions aimed at improving
patients’ participation in safety (Davis et al. 2013a, Rainey
et al. 2013).
Discussion
Although there is an international movement to increase
patients’ involvement in patient safety, there is insufficient
evidence of benefit (Hall et al. 2010). This systematic
review has described patients’ participation in patient safety
practices using Vincent’s framework of influences on clini-
cal practice. This framework depicts the comprehensive and
synergistic role of different aspects in safety management
and provides a guideline for clinical nurses and nurse man-
agers to involve patients in safety practices. The factors
involved might be summarised as: ‘education’, ‘the work-
place’ and ‘the organisation systems’ (Griffith et al. 2003).
Education for professionals and patients
Education is a key component of patient participation
(Schwappach & Wernli 2010a, Schwappach et al. 2010).
Nurses’ positive attitudes, encouragement, support, knowl-
edge and education are central to patient participation in
safety practices. This parallels the general recommendation
to healthcare professionals that there is a need to proactive-
ly approve and support patient involvement in healthcare
(Entwistle & Watt 2006). Professional education initiatives
(Wakefield et al. 2010) are needed to maximise the value of
these initiatives (Longtin et al. 2010). Informing patients
about the reasons for nursing and medical interventions,
and increasing patients’ trust in their own abilities to iden-
tify errors can reduce errors (Schwappach & Wernli
2010b). Both patients and professionals require education
and guidelines, checklists or pro formas on how to commu-
nicate errors to each other appropriately and respectfully,
without causing offence (Rainey et al. 2013, Schwappach
et al. 2013a), and examples related to medicines’ manage-
ment have been described (Gabe et al. 2014, Jordan et al.
2014).
© 2014 John Wiley & Sons Ltd
Journal of Clinical Nursing
Patient participation and patient safety
The basis of patient safety is the assumption that patients
are able and are willing to participate (Schwappach 2010).
However, practice guidelines should accommodate individ-
ual patient preferences, permitting disengagement from
active participation (Bovenkamp & Trappenburg 2009).
Patient education to improve patient participation
requires: provision of information on available participation
modalities (Entwistle 2007, Bovenkamp & Trappenburg
2009, Pittet et al. 2011), improvement of patients’ capaci-
ties for taking responsibility (Davis et al. 2007, 2008) and
behaviour changes (Schwappach 2010). Patients’ attitudes
and beliefs, personal strategies to deal with healthcare con-
cerns, and previous emotional experiences within the
healthcare system are central to patient participation (Davis
et al. 2007, Longtin et al. 2010). These are important in
the management of long-term conditions, where patients
have time to assimilate knowledge of their conditions, and
opportunity to become ‘expert patients’. Expert patients
have the information resources to meet the needs of their
chronic illnesses, and are often able to self-care and manage
their own conditions (Wilson 2001). For example, interven-
tions aiming to encourage patient involvement in medicines’
monitoring and self-management of medication in hospital
have been successful (Hall et al. 2010).
Moreover, nurses’ positive attitudes, encouragement and
support, and education were identified as factors influenc-
ing patient participation in safety practices. This parallels
the general recommendation to healthcare professionals
that there is a need to proactively approve and support
patients’ knowledge and involvement (Entwistle & Watt
2006). Provision of information on the available participa-
tion modalities (Bovenkamp & Trappenburg 2009),
improvement of patients’ capacities for taking responsibility
in safety practices (Davis et al. 2007, 2008), facilitating or
reinforcing patients’ understanding of how they can partici-
pate (Entwistle 2007, Pittet et al. 2011), and behavioural
changes (Schwappach 2010) improve patient participation,
and should be incorporated into professional education
(Longtin et al. 2010). Professional educational interven-
tions, such as peer-modelling behaviour (Wakefield et al.
2010), are needed to maximise the value of patient safety
initiatives (Longtin et al. 2010).
Workplace environment
The healthcare workplace environment is important in
patient participation. A system that supports patient safety
is characterised by advertising patient-centredness and
mutual acknowledgement. Patients’ actions are complemen-
tary to professionals’ efforts to preserve patient safety, and
9
M Vaismoradi et al.
it should not mean that the responsibility of the safety of
care should not devolve to patients (Davis et al. 2007).
Patients’ interests and abilities to improve their own knowl-
edge of the care process and also to inform healthcare pro-
fessionals of probable errors are assets to the healthcare
system (Lyons 2007).
The main strategy for patient participation in safety prac-
tices is to encourage patients to ask questions without fear
of causing offence to healthcare providers. Agreement on
the style of asking questions by patients should provide an
atmosphere of trust between patients and healthcare profes-
sionals to ensure that challenging the activities of staff does
not offend them (Davis et al. 2008, 2011b). Before mea-
sures for patient involvement are introduced, consideration
should be given to the potential physical and psychological
burdens placed on patients (Ward & Armitage 2012).
Organisation
Patient empowerment depends on feeling valued, safe and
motivated to participate (W ahlin et al. 2006). Today’s
healthcare systems consider themselves patient-centred
rather than provider-centred (Berwick 2009, Jangland et al.
2012), emphasise collaboration between patients, families,
and healthcare providers, and aim for an organisational cul-
ture that supports patient safety (Johnson et al. 2010).
While not all retrieved studies have discussed the role of
the healthcare team in patient participation, Schwappach
et al. (2010) reported that nurses perceived patients’
involvement challenging. Although support from other team
members and professional development were helpful, the
main barriers were fluctuations in team organisation and
roles. Similarly, a busy healthcare setting and lack of conti-
nuity of care were reported by Doherty and Stavropoulou
(2012) as barriers to preventing patients’ active involvement
in safety: work pressure and staff shortages made patients
to wary of engaging in error prevention behaviours.
Patient participation needs a supportive management sys-
tem that continuously identifies and addresses any and all
system weaknesses and failures that arise (Lyons 2007),
and is committed to support involvement challenge power
inequities and empower patients (Ocloo & Fulop 2012).
Patient empowerment depends on feeling valued, safe and
motivated to participate (W ahlin et al. 2006).
Conclusion
Obtaining durable benefits from patients’ active participa-
tion in patient safety depends on recognising factors affect-
ing patients’ willingness to act as a member of the patient
10
safety team (Davis et al. 2007). We found few data on
patient participation in patient safety in developing coun-
tries. Future work should assess interventions aimed at
improving patients’ participation in safety, and the condi-
tions necessary for patient, family, professional and organi-
sational involvement in different healthcare settings, such as
acute and long-term care, in developed and developing
countries (Peat et al. 2010, Davis et al. 2013a, Rainey et al.
2013).
We found no studies on the economic costs and benefits
of these initiatives.
Limitations of this review
Patient participation is a relatively new topic in the inter-
national patient safety literature. Therefore, many aspects
of this important concept remain unknown. No manual
search was conducted on the grey literature, but the elec-
tronic search in the international high-quality databases
convinced the researchers that a broad search area has
been covered to provide a comprehensive answer to the
study question.
Relevance to clinical practice
This review suggests the need for comprehensive practice
guidelines to support improving patient participation in
patient safety. Improvement of patient participation in
patient safety depends on the consideration of the patient
as a person, the nurse as healthcare provider, the task of
participation and the nursing ward as healthcare environ-
ment. Patients’ roles should be defined, with due consider-
ation for any limitations in physical abilities and
knowledge, belief and attitudes. Nurses should use patient
participation as a learning process, assist patients to partici-
pate in their own care, and avoid taking an authoritarian
approach that may discourage participation (Schwappach
et al. 2010, Davis et al. 2013b). The nature of the task
given to the patient should be congruent with patients’
knowledge of nursing routines, and their capacity to imple-
ment their tasks. The healthcare setting should value
patient participation and provide appropriate strategies to
facilitate their full engagement in safety practices. A sche-
matic model of how the patient can participate in all
patient safety initiatives has been presented in Fig. 2. To
guide the development of practical strategies for establish-
ment and improvement of patient participation in patient
safety in clinical practice we suggest as follows:
• Patients’ knowledge, attitudes and beliefs should be
assessed;
© 2014 John Wiley & Sons Ltd
Journal of Clinical Nursing
Review Patient participation and patient safety

• Interventions to enhance willingness to participate in
safety initiatives should be evaluated;
• Enough support in terms of motivation, encouragement
and help should be provided to patients and their col-
laboration should be valued and respected.
• Both patient and healthcare provider should be educated
on the importance of patient participation in patent
safety.
• Patient participation should be incorporated into health-
care providers’ description of duties and the process and
expectations of such a collaboration should be outlined.
• The level of collaboration by the patient should be con-
gruent with his/her health condition and physical and
psychological abilities, and the nature of task.
• Healthcare organisations should provide the necessary
resources and infrastructures for patient participation
and encourage healthcare team members’ collaboration
consistent with the mission of safer healthcare systems.
during preparation and development of this article. We
acknowledge her kind efforts, expertise and help. Her
absence from the team is deeply regretted by all of us.
Disclosure
The authors have confirmed that all authors meet the
ICMJE criteria for authorship credit (www.icmje.org/ethi
cal_1author.html), as follows: (1) substantial contributi-
ons to conception and design of, or acquisition of data
or analysis and interpretation of data, (2) drafting the
article or revising it critically for important intellectual
content, and (3) final approval of the version to be pub-
lished.
Funding
Swansea University and University of Eastern Finland pro-
vided facilities and support for this project.

Acknowledgements
Conflict of interest
It is with great sadness that we were informed of the death
of our dear colleague and co-author, Prof. Melanie Jasper, No conflict of interest is declared by the authors.

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